Chapter 10 Immobilization and splinting
Orthopedic Emergencies, ed. Michael C. Bond, Andrew D. Perron, and Michael K. Abraham. Published by Cambridge University Press. © Cambridge University Press 2013.
General
Splint material (Figures 10.1 and 10.2)
Stockinette (Figure 10.1C) – a cloth sleeve that helps provide protection to the skin, and helps to hold the splint in place during application. Also gives a cleaner appearance to the splint/cast.
Plaster of Paris (Figure 10.2B) – available in sheets or rolls. Sheets typically come 5 inches wide in 30- or 45-inch lengths. Eight to ten sheets typically needed for upper-extremity splints, and 15–20 sheets for lower-extremity splints. Width and length can easily be adjusted to the patient’s needs by ripping or cutting the sheets. Plaster of Paris takes approximately 20 minutes to cure and a full day to reach maximum strength. The curing process is an exothermic reaction, so patients may complain of significant heat and can suffer burns. The risk of excessive heat production increases with the number of sheets used and if the water used to wet the plaster of Paris is hot
Fiberglass (Figure 10.1D) – (e.g., Orthoglass®, Scotchcast®) sold as rolls of fiberglass wrapped in cotton padding. Supplied in predetermined widths (2″, 3″, 4″, 5″, and 6″). Fiberglass requires minimal water to aide the activation process, will cure and reach maximum strength in about 20–30 minutes. Not as moldable as plaster of Paris. Care needs to be made to trim or cover the cut edges in order to prevent fiberglass barbs from poking the patient. Orthoglass® has the same padding on both sides of the splint, whereas Scotchcast® has padding on one side and a breathable backing on the other
Cast padding (e.g., Webril™) (Figure 10.1A and Figure 10.2C) – rolls of cotton padding that must be used with plaster of Paris. Care should be taken to prevent creases or lumps as this can lead to pressure points that can result in skin breakdown and pain. Typically two to three layers provide enough padding. Additional layers should be used on bony prominences
Elastic bandage (Figure 10.1B and Figure 10.2D) – used to hold the splint in place. Do not apply with excessive force as this can lead to numbness and reduced blood flow
Sugar tong splint (Figure 10.3)
Indications
Radius and ulna fractures
Supracondylar humeral fractures
Carpal bone fractures
PEARL: The sugar tong splint prevents flexion and extension at the wrist, supination, pronation, and greatly inhibits flexion and extension at the elbow. Can be combined with a second sugar tong splint (double sugar tong) that starts at the axilla and wraps around the elbow to the shoulder. This double sugar tong will prevent all flexion and extension at the elbow.
Figure 10.3 Traditional sugar tong splint. Used for fractures of the radius, ulna, carpal bones, and supracondylar fractures. Note the final hand position.
Materials
Stockinette
Plaster of Paris or fiberglass splint
Cast padding
Elastic bandages
Application
Two methods possible
Traditional sugar tong (Figure 10.3)
Apply stockinette from the hand to mid-bicep
Measure splinting material (plaster of Paris, or fiberglass) from the dorsum of the hand, around the elbow, to the volar surface of the hand
Ensure that the width is thin enough that it does not come up the sides of the forearm, which would essentially form a circumferential cast. Most splints will be 2 or 3 inches wide (5 to 7.5 cm)
If using plaster of Paris, roll out two to three layers of cast padding. Consider adding additional padding over areas of bony prominence
Wet the plaster of Paris, or slightly dampen the fiberglass splinting material
Apply the cast padding to the wet splint material, and apply to the arm as one unit starting at the hand, wrapping around the elbow and returning to the hand (Figure 10.4). Splinting material can bunch up at the elbow (Figure 10.5)
Starting at the hand, apply elastic bandages to hold the splint in place. Make sure not to to apply the elastic bandages too tightly
Once the splint is applied, the hand and wrist should be placed in the position of function
Figure 10.4 Traditional sugar tong splint with the fiberglass placed over the stockinette. The splint should go from the dorsal side of the hand, wrap around the elbow, and return to the volar side of the hand.
Figure 10.5 Demonstrates the bunching that can occur with the splinting material at the elbow.
Double sugar tong splint
Indications
Humerus fractures
Supracondylar fractures
Radius and ulna fractures
Carpal bone fractures
Materials
Stockinette
Plaster of Paris or fiberglass splint
Cast padding
Elastic bandages
Application
Apply stockinette from the hand to axilla
Measure 2 pieces of splinting material (plaster of Paris, or fiberglass). The first will go from the axilla, around the elbow and wrap back up the arm to the shoulder. The second piece will go from the dorsum of the hand, wrap around the elbow, to the volar surface of the hand
Most splints will be 2 or 3 inches wide (5 to 7.5 cm)
If using plaster of Paris, roll out 2–3 layers of cast padding. Consider adding additional padding over areas of bony prominence
Wet the plaster of Paris, or slightly dampen the fiberglass splinting material
Apply the cast padding to the wet splint material, and apply to the arm as two units. The first unit will be applied from the axilla, wrap around the elbow, and extend back up to the shoulder. The second unit will extend from the dorsum of the hand, wrap around the elbow, and extend back to the volar surface of the hand
Starting at the hand, apply elastic bandages to hold the splint in place. Make sure not to apply the elastic bandages too tightly
Once the splint is applied, the hand and wrist should be placed in the position of function, and the elbow flexed at 90°
Reverse sugar tong splint (Figure 10.6)
Apply stockinette from the hand to mid-bicep
Measure splinting material (plaster of Paris, or fiberglass) from the dorsum of the hand, around the elbow, to the volar surface of the hand
Ensure that the width is thin enough that it does not come up the sides of the forearm, which would essentially form a circumferential cast. Most splints will be 2 or 3 inches wide (5 to 7.5 cm)
If using plaster of Paris, roll out two to three layers of cast padding. Consider adding additional padding over areas of bony prominence
Fold the splint in half, and in the middle, cut through the splinting material except for a small piece (∼1/2 inch [1 cm]) (Figure 10.7)
Wet the plaster of Paris, or slightly dampen the fiberglass splinting material
Apply the cast padding to the wet splint material, and apply to the arm as one unit starting at the hand. The area that was not cut should be placed in the webspace of the first and second digits of the hand, with the splint hanging down from the hand (Figure 10.8)
Starting at the hand, apply elastic bandages to hold the splint in place. Make sure not to apply the elastic bandages too tightly
Once the splint is applied, the hand and wrist should be placed in the position of function
Figure 10.6 A reverse sugar tong splint. The splinting material is cut so that it can rest in the first and second web space, and then drapes down the arm, where the ends can be wrapped around the elbow. More easily held in place while wrapping with elastic bandages than a traditional sugar tong, and prevents some of the bunching of splint material at the elbow.
Figure 10.7 Fold the splinting material in half and cut through the material, leaving about 1 cm uncut.
Figure 10.8 Reverse sugar tong shown in place with the uncut splint material resting in the first and second web space.
Volar splint (Figure 10.9)
Indications
Carpal bone fractures
Metacarpal bone fractures
Carpal tunnel syndrome
Soft-tissue injuries of wrist
PEARL: A volar splint prevents flexion and extension at the wrist and metacarpal joint if extended into the fingers.
Materials
Stockinette
Plaster of Paris or fiberglass splint
Cast padding
Elastic bandages
Application
Apply stockinette from the hand to mid-forearm
Measure splinting material (plaster of Paris, or fiberglass) along the volar side of the hand from the mid-fingers to the mid-forearm
Most splints will be 2 or 3 inches wide (5 to 7.5 cm)
If using plaster of Paris, roll out two to three layers of cast padding. Consider adding additional padding over areas of bony prominence
Wet the plaster of Paris, or slightly dampen the fiberglass splinting material
Apply the cast padding to the wet splint material, and apply to the arm as one unit starting at the distal hand along its volar surface (Figure 10.10)
Starting at the hand, apply elastic bandages to hold the splint in place. Make sure not to apply the elastic bandages too tightly
Once the splint is applied, the hand and wrist should be placed in the position of function
Figure 10.10 A volar splint being placed. The stockinette is in place and the splinting material is placed on the volar surface of the hand/wrist.
Dorsal splint (Figure 10.11)
Indications
Carpal bone fractures
Metacarpal bone fractures
Carpal tunnel syndrome
Soft-tissue injuries of wrist
PEARL: A dorsal splint prevents flexion and extension at the wrist and metacarpal joint if extended into the fingers.
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